Frank Phillips College Vocational Nursing Department 1301 W. Roosevelt P.O. Box 5118 Borger, TX ext

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1 Frank Phillips College Vocational Nursing Department 1301 W. Roosevelt P.O. Box 5118 Borger, TX ext KEEP THIS INFORMATION TO REMIND YOU OF NEEDED REQUIREMENTS. THE FOLLOWING ENTRANCE REQUIREMENTS HAVE BEEN LISTED FOR YOU AS A GUIDELINE FOR APPLICATION TO THE VOCATIONAL NURSING PROGRAM. 1. Applicants to the Vocational Nursing Program must meet the general admission requirements including taking the college entrance test, as written in the FPC college catalog. Complete the Frank Phillips College, Application for Admission and return to the appropriate address. The application is located on the college website: Applicants will need to call Student Central at , ext. 844 to schedule the TSI college entrance test. 2. The applicant must complete a Vocational Nursing application for entry into the program. Fill in each blank on the student application forms. Return both pages of the Vocational Nursing application (pages 3 & 4) and the Texas Board of Nursing Eligibility Questions (page 5) to the Nursing Department by Friday, May 15, Please submit your application as soon as possible so we may start your file. 3. IMPORTANT CHANGE: The Texas Board of Nursing now requires students to be Board approved before entering a Nursing program. Therefore, FPC nursing program will require all students to undergo their DPS/FBI criminal fingerprint background check during the Spring/Summer, so results can be obtained before August 1, Students with a clear background will be mailed a blue card Students who have a positive criminal history will be required to go through the declaratory order process. If the nature of the issue can be resolved within the delegated authority of the Operations Department, there will be no charge and the student will be sent an operations outcome letter stating that they will be allowed to take the NCLEX upon graduation. If the nature of the criminal issue is beyond the delegated authority of the Operations Department and must be transferred to the Enforcement Department for review, the student will be billed a $150 review fee. Only upon receipt of the fee will the file be transferred to the Enforcement Department for review. This step could take up to 90 days. Students must provide blue card, operations outcome letter, or enforcement letter to the FPC nursing office by August 1, This change makes it very important to submit applications as soon as possible so your name can be added to the roster submitted to the Texas BON. Please see the Texas Board of Nursing website: for more information. 4. The Vocational Nursing Student Policies are located on the FPC Vocational Nursing web page. Applicants must print and read all of the VN Student Policies and sign the FPC Vocational Nursing Program Policy Statement (pages 22-25). The signed forms must be submitted to the Nursing Department by May 15, Signing of the policy statement constitutes an agreement to abide by the policies. 5. A physical examination by your physician is necessary upon acceptance to the nursing program. The required form is attached (page 6) and the original form must be returned to the Nursing Department by August 1, The physical examination cannot be dated prior to May 15,

2 6. A record of immunizations, physical exam, and TB test results must be on file in the Nursing Department by August 1, The attached Immunization Form (pages 7 & 8) must be completed and returned to the Nursing Department. Proof of immunizations, i.e. Immunization record, must be submitted with the form or the physician/nurse/pharmacist who administered the immunization may sign the form for verification. DO NOT WAIT TO START YOUR IMMUNIZATIONS! Accepted nursing students will not be allowed to start clinical classes in the fall semester unless all required immunizations are complete. 7. A copy of your high school transcript, your GED test scores, and/ or Official transcripts from all colleges previously attended must be received in the Nursing Department by August 1, 2015 Applicants will not be considered for acceptance to the nursing program without transcripts or GED test scores. 8. The HESI admission assessment exam is required. You must make an appointment with the Nursing Department to take this test on one of the scheduled dates. A testing schedule is available on the Vocational Nursing webpage, on the FPC website, or call the nursing department for dates & times. It is important to test early! A $50.00 testing fee must be paid before taking the HESI. You may pay the fee on the day of your scheduled test. For returning students, test scores must be 2 years old or less. Scores older than 2 years require the applicant to retest. If you do not obtain the minimum scores on the HESI test on your first attempt you will be allowed to retake the test one time Reference letters. One letter MUST be from a former teacher (high school or college). One letter MUST be from a former employer or coworker. Letters must be mailed to Frank Phillips College Nursing Dept. 10. Applicants will be required to meet with the FPC nursing faculty for an advising session prior to acceptance in the Vocational Nursing Program. If you have any questions or need help with your application, call the Nursing Department at the number above. Send completed application to: Frank Phillips College Vocational Nursing Department P.O. Box 5118 Borger, Texas Revised 1/2015 Frank Phillips College is an equal opportunity Community College. The information required on this application is subject to change without notice. 2

3 Frank Phillips College 1301 W. Roosevelt P.O. Box 5118 Borger, TX , ext VOCATIONAL NURSING APPLICATION STUDENT APPLICATION : To be returned to the Vocational Nursing Department Name Last First Middle Soc. Sec. # Other names known by: of Birth Ethnic Group (circle one) White Black Hispanic Asian/Pacific Islander American Indian/Alaskan Mailing Address City State Zip Phone In the blanks below name the schools you have attended, their location, and the grades you completed. Include other names you may have been registered as. High School College Other Schooling Have you ever attended any nursing program? Grade Completed Grade Completed Grade Completed If yes, what type? Name and Address of Nursing School attended Reason for withdrawal Do you authorize your doctor(s) to release our health records to this agency? Yes No List last two employers (including present). Give names, addresses, city, state, and zip. 1. Employer Name & Address s of Employment: Job Title 3

4 2. Employer Name & Address s of Employment: Job Title EMERGENCY CONTACT: TWO (2) PEOPLE & PHONE NUMBERS WHO DON'T LIVE WITH YOU I certify that the above statements are true and correct. I authorize FPC Vocational Nursing Program to investigate my personal history or work record if necessary. I understand that my eligibility is based on the results of the HESI test, background verification, recommendation letters and advising session interview. Signature of Applicant Please list your clinical site. List your first three choices. If you do not select a clinical site, one will chosen for you. CLINICAL SITE CHOICES ARE: 1. Borger Dumas Dalhart 2. Perryton Pampa 3. Please give the following information on courses you have completed: Course Name Credit Hours Grade College where credit earned BIOL 2401 BIOL 2402 HITT 1305 PSYC 2301 BIOL 1322 A&P I A&P II Medical Terminology General Psychology Elementary Nutrition Have you applied at Frank Phillips College Nursing Department before? If yes, list year: Have you passed TSI, or other approved college entrance test: Yes No Indicate which test you have taken: Score Revised 1/2015 4

5 Texas Board of Nursing 333 Guadalupe, 3-400, Austin, TX (1) Social Security Number Telephone Number: (2) Last Name: First Name: (3) Middle Name: Maiden Name: Suffix (Jr. II): (4) Current Mailing Address: Apt#: (5) City: State: Zip + 4: (6) Name of School: (7) City : (8) Graduation date: Eligibility Questions 1) [ ] No [ ] Yes For any criminal offense, including those pending appeal, have you: A. been convicted of a misdemeanor? B. been convicted of a felony? C. pled nolo contendere, no contest, or guilty? D. received deferred adjudication? E. been placed on community supervision or court-ordered probation, whether or not adjudicated guilty? F. been sentenced to serve jail or prison time? court-ordered confinement? G. been granted pre-trial diversion? H. been arrested or any pending criminal charges? I. been cited or charged with any violation of the law? J. been subject of a court-martial; Article 15 violation; or received any form of military judgment/punishment/action? (You may only exclude Class C misdemeanor traffic violations.) NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended that you submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, will at a minimum, subject your license to a disciplinary fine. Nondisclosure of relevant offenses raises questions related to truthfulness and character. NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov t Code (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Gov t Code chapter 411, the Texas Nursing Board is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may require you to provide information about that criminal matter. 2) [ ] No [ ] Yes Are you currently the target or subject of a grand jury or governmental agency investigation? 3) [ ] No [ ] Yes Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license, certificate or multi-state privilege held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? 4) [ ] No [ ] Yes Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug? 5) [ ] No [ ] Yes Within the past five (5) years have you been diagnosed with, treated, or hospitalized for schizophrenia and/or psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder? If YES indicate the condition: [ ] schizophrenia and/or psychotic disorders, [ ] bipolar disorder, [ ] paranoid personality disorder, [ ] antisocial personality disorder, [ ] borderline personality disorder If you answered YES to any of the questions listed above, you must apply for a Declaratory Order through the Board of Nursing prior to applying to the Frank Phillips College Vocational Nursing Program. Information on Declaratory Orders can be located at the Board of Nurse Examiners Web site at: SIGNATURE: DATE: Reviewed 1/2015 5

6 FRANK PHILLIPS COLLEGE VOCATIONAL NURSING DEPARTMENT P.O. Box 5118 Borger, TX PHYSICAL EXAMINATION OF APPLICANT 1. Name 2. Address Phone 3. Age Height Weight 4. Past History: illnesses, operations, & injuries (complete with dates) 5. Eyes: Vision: R L With Glasses: R L 6. Ears: Condition: R L Hearing: R L 7. Nose: Sinuses: 8. Teeth: Tonsils: 9. Thyroid: Skin: 10. Heart: Lungs: 11. Abdomen: Hernia: 12. Feet: R L Varicose Veins: 13. Back: 14. Posture: Reflexes: Defects found: Corrections made or recommended: In your opinion, is this individual in suitable physical and emotional condition to pursue vocational nursing education? If not, why? Signature of examining physician Address City State Zip Telephone Original form must be returned to the Vocational Nursing Department!!! Reviewed 1/2015 6

7 Nursing Immunizations and Tests Required by State Law/Clinical Facilities Name: of Birth: Program: FPC ID#: Measles (Rubeola): Those born on or after January 1, 1957, must show proof of either: A. Two doses of measles vaccine on or after their first birthday and at least 30 days apart OR *See note. #1 #2 B. Record of physician-diagnosed measles OR C. Serologic test positive for measles antibody Result Mumps: Those born on or after January 1, 1957, must show proof of either: A. One dose of mumps vaccine on or after their first birthday OR B. Record of physician-diagnosed mumps OR C. Serologic test positive for mumps antibody Result Rubella: Those born on or after January 1, 1957, must show proof of either: A. One dose of Rubella vaccine on or after their first birthday OR B. Record of physician-diagnosed Rubella OR 7

8 C. Serologic test positive for Rubella antibody Result *Combined MMR Vaccine is vaccine of choice if recipients are likely to be susceptible. **Must be the date of diagnosis or test collection; not when primary care provider signed immunization form. +Vaccines administered after September 1, 1991 shall include the MM/DD/YY each vaccine was given. Hepatitis B must show proof of: A. Three doses of vaccine administered over a period of 4 to 6 months OR There Is a 4 month accelerated series approved by the CDC and TDHS. Administer vaccine at 1 st month, 2 nd month, & 4 th month. #1 #2 #3 B. Serologic test positive for Hepatitis B antibody Result Varicella must show proof of: A. Two doses of Varicella vaccine administered 4-8 weeks apart OR #1 #2 B. Serologic test positive for Varicella antibody OR Results C. Physician documented history of diagnosis of Varicella Disease Occurred Diphtheria, Tetanus (TD): One dose within past 10 years Meningococcal Tuberculin Test (PPD): Administered Read: 8

9 Must be performed annually *Or copy of chest x-ray report if reactive PPD Results: Test Read By: Primary Care Provider Information: Printed Name Address Signature of Primary Care Provider Original form must be returned to the Vocational Nursing Department!!! Reviewed 1/2015 9

10 STUDENT CHECK LIST Use this form as a checklist of your application process. Once it is complete, you know your file is complete. Please do not wait to turn in your application till you have all these items. Turn in your application and then fill in items as they come in. Apply to FPC TSI complete Student Application (return ASAP) BNE questionnaire (pg 5 of application packet) HESI Entrance Exam (schedule time) College Transcripts (all colleges attended) H.S. Transcripts (only if no college transcript) Immunizations / shots needed Physical (after May 15 st and before Aug. 1st) Background/ FBI fingerprint Policies (on website) Reference letters (2) D.O. (if app. Due to activity on background check) Attend Orientation (TBA) Blue Card Letter of Eligibility 10